Arterialization of epigastric skin flaps in rabbits

Summary This preliminary experimental investigation revealed that arterial blood supply via the inferior epigastric vein (reversed blood flow) nourished an epigastric skin flap well enough to survive. Histological examinations showed no differences between skin of the flap and normal skin (Figs. 4, 5). Free nonvascularised skin flaps (group 1) showed necroses and secondary wound healing. However, the question remains unsolved whether or not the blood flow is re-reversed again postoperatively and how circulation of the flap stabilizes after the first postoperative days.     

Skin paddle vascularity of free fibula flap �C A study of 386 cases and a classification based on contribution from axial vessels of the leg

Objective:

The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems.

Materials and Methods:

A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study.

Results:

The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg.

Conclusion:

The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.KEY WORDS: Free fibula flap, musculocutaneous perforators, septo cutaneous perforators, skin paddle, vascular supply     

桥式游离背阔肌肌皮瓣在下肢软组织缺损中的应用

目的　观察应用桥式游离背阔肌肌皮瓣修复下肢软组织缺损的效果。　方法　采用桥式游离背阔肌肌皮瓣修复7例下肢严重软组织损伤患者。术前对拟行移植的背阔肌肌皮瓣血管和健肢血管行超声多普勒检查,以确认皮瓣及健肢血管循环良好。清创后,根据创面大小、深度设计皮瓣,用作携带桥的皮瓣长度较双下肢手术部位之间距离长10%左右;供区面积较受区大20%,形成皮管部位的皮肤设计应宽大,避免张力过大对血管造成压迫。然后行皮瓣修复术。观察皮瓣成活情况,总结手术指征及应注意的问题。　结果　7例患者手术后皮瓣均成活。除2例患者因皮瓣较为臃肿行皮瓣修薄术外,其余患者术后外形良好,功能恢复满意。手术指征:患侧肢体一条主要的动脉(胫前或胫后动脉)受损,不宜用另一条动脉作吻合血管行游离皮瓣移植术者;患侧肢体受伤严重,深层组织结构破坏,血管损伤情况不明或估计难以找到受区血管者;对侧健肢的重要血管无损伤者。注意点:术前应考虑桥式皮瓣的血运及断蒂后皮瓣是否能够成活。术后注意皮瓣血运,术区妥善固定。　结论　桥式游离背阔肌肌皮瓣修复下肢软组织缺损效果满意。恰当的创面处理、宽大的皮瓣、稳妥的固定是手术成功的关键。     

Aesthetic considerations in facial reconstructive surgery: The V-Y flap revisited

The subcutaneous pedicled V-Y advancement flap (also known as the kite flap of Dufourmentel) has been described by many authors. Its versatility in reconstructive surgery is well known, both in facial reconstructive surgery as well as surgery of the trunk and extremities. Its advantages in achieving aesthetic reconstruction in specific facial regions have been less well emphasized in the literature. The flap can be designed within natural facial creases and heals inconspicuously because of its widely based subcutaneous or muscle pedicle which incorporates venous and lymphatic drainage over most of its length. The undesirable biscuiting or flap edema frequently observed with other conventional transposition flaps is avoided. We have found the V-Y flap particularly useful in reconstructing the lower eyelid/medial canthus, supra-alar, and nasolabial regions. Our experience with over 40 such flaps is described, and technical considerations in designing and elevating the flap are discussed.     

Versatility of rectus abdominis free flap for reconstruction of soft-tissue defects in extremities

Rectus abdominis flaps, whose blood supply is mainly provided by superior and deep inferior epigastric vessels, are suitable not only for local transfer but also as free flaps. Based on abundant anastomoses of deep inferior epigastric vessels with other vessels such as superior epigastric vessels, lower intercostal vessels, subcostal vessels, lumbar vessels, superficial epigastric vessels, and superficial and deep iliac circumflex vessels, the rectus abdominis flap may be designed as a vertical flap, transverse flap, or oblique flap. From September 1995-October 2002, 42 free rectus abdominis flaps were transferred to reconstruct a variety of soft-tissue defects. The size of rectus abdominis flaps ranged from 6-25 cm in length and 5-12 cm in width. The overall success rate was 100% (42 of 42). The donor area was closed directly in 8-10-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. After a mean 7-month (range, 3 weeks-18 months) follow-up, all flaps have healed uneventfully, and donor abdominal morbidity is minimal.     

The musculo-cutaneous cross leg flap

Summary The authors present a musculo-cutaneous cross leg flap using the medial head of the gastrocnemius muscle to cover a defect of the contralateral foot resulting from a chronic traumatic ulcer. The inclusion of the well vascularized muscle portion into a compound flap increases the safety of the cross leg procedure. The functional and aesthetic defect of the donor site is minimal.When this paper was submitted for publication an article The Versatile Gastrocnemius Myocutaneous Flap appeared in Plastic and Reconstructive Surgery 62, 15 (1978) by J.B. McCraw, J.H. Fishman, and L.A. Sharzer, who also emphasized the use of a musculocutaneous flap in a cross leg procedure.     

Avoidance of complications after the use of deep inferior epigastric perforator flaps for reconstruction of the breast.

We assessed 50 consecutive unilateral deep inferior epigastric perforator (DIEP) flaps for breast reconstruction to find out our morbidity and how to avoid it. We routinely dissected the superficial epigastric vein bilaterally and perforators ipsilaterally. If there were insufficient perforators on the ipsilateral side, we then dissected the contralateral side. We made an additional anastomosis to the superficial epigastric vein in cases of venous congestion after reperfusion that could threaten flap survival. One perforator was used on 31 occasions, and the contralateral side was dissected in 16. A prophylactic anastomosis of superficial epigastric vein was done in 3. No flap was lost completely but 5 partially necrosed. A comparison of the first 25 and the second 25 flaps showed more dissections of the contralateral side and more prophylactic anastomoses of the superficial epigastric vein in the second 25. Partial necrosis was less common in the second 25. We suggest that more liberal dissection of the contralateral side and the prophylactic anastomosis of the superficial epigastric vein to lower morbidity and give better cosmetic results.     

New options in breast reconstructive surgery: Alternatives to the latissimus dorsi musculocutaneous flap

Transposition of the latissimus dorsi musculocutaneous flap is still considered by most authors a first-choice technique for breast reconstruction. However, the aesthetic drawbacks of the technique are significant: In our experience the posterior scar and the patchlike skin island are of concern to more than 30% of patients. Recent alternatives have sharply reduced the use of the latissimus dorsi myocutaneous flap as our first-choice technique. The utilization of a latissimus dorsi muscular flap in association with submuscular placement of a tissue expander is now our favorite technique for the majority of patients: Residual scarring is insignificant since the whole muscle can be raised through a 5–7-cm-long, S-shaped incision placed along the anterior border of the latissimus dorsi. The results obtained in a group of 35 patients demonstrate that the final results of the procedure in terms of shape and projection of the reconstructed breasts are absolutely similar to those obtained using the latissimus dorsi musculocutaneous flap. However, in patients with heavy body structure and large contralateral breast, satisfactory symmetry and a natural-looking reconstructed breast are obtained more effectively by transposition of a rectus abdominis myocutaneous flap. The precautions to be taken in order to make the procedure suitable for overweight patients are described and the results are discussed.     

Avoidance of complications after the use of deep inferior epigastric perforator flaps for reconstruction of the breast

We assessed 50 consecutive unilateral deep inferior epigastric perforator (DIEP) flaps for breast reconstruction to find out our morbidity and how to avoid it. We routinely dissected the superficial epigastric vein bilaterally and perforators ipsilaterally. If there were insufficient perforators on the ipsilateral side, we then dissected the contralateral side. We made an additional anastomosis to the superficial epigastric vein in cases of venous congestion after reperfusion that could threaten flap survival. One perforator was used on 31 occasions, and the contralateral side was dissected in 16. A prophylactic anastomosis of superficial epigastric vein was done in 3. No flap was lost completely but 5 partially necrosed. A comparison of the first 25 and the second 25 flaps showed more dissections of the contralateral side and more prophylactic anastomoses of the superficial epigastric vein in the second 25. Partial necrosis was less common in the second 25. We suggest that more liberal dissection of the contralateral side and the prophylactic anastomosis of the superficial epigastric vein to lower morbidity and give better cosmetic results.     

Propeller flap reconstruction of abdominal defects: Review of the literature and case report

The abdominal wall is perfused anteriorly by the superior and deep epigastric vessels with a smaller contribution from the superficial system. The lateral abdominal wall is perfused predominantly from perforators arising from the intercostal vessels. Reconstruction of soft tissue defects involving the abdomen presents a difficult challenge for reconstructive surgeons. Pedicle perforator propeller flaps can be used to reconstruct defects of the abdomen, and here we present a thorough review of the literature as well as a case illustrating the perforasome propeller flap concept. A patient underwent resection for dermatofibrosarcoma protuberans resulting in a large defect of the epigastric soft tissue. A propeller flap was designed based on a perforator arising from the superior deep epigastric vessels and was rotated 90° into the defect allowing primary closure of the donor site. The patient healed uneventfully and was without recurrent disease 37 months following reconstruction. Perforator propeller flaps can be used successfully in reconstruction of abdominal defects and should be incorporated into the armamentarium of reconstructive microsurgeons already facile with perforator dissections. © 2014 Wiley Periodicals, Inc. Microsurgery 35:72–78, 2015.     

Vein coupler to simplify the end-to-side microanastomosis

Summary Judicious use of a short segment of a reversed autogenous vein graft may facilitate certain microanastomosis serving as a coupler between recipient and donor vessels. This technique is of particular value for simplifying end-to-side anastomoses with diseased recipient arteries, and simultaneously allows enhancement of flow by creation of a wide opening. This concept may also be applied to circumvent a significant size discrepancy between flap and inflow vessels.     

Re: a new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report

Wang and colleagues described the use of fasciocutaneous flap based on deep inferior epigastric perforator (DIEP) vessels for vaginal reconstruction. They presented four patients with congenital vaginal agenesis and one with vaginal tumor. The rhombus-shaped abdominal flap was designed according to the location of deep inferior epigastric vessels perforators. The size of the flap ranged from 9 x 12 to 11 x 12 cm. The flap was elevated without underlying muscle, dissecting perforators together with the pedicle-deep inferior epigastric vessels up to their origin. The fully mobilized flap was tabularized, transposed paravesically to the previously prepared vaginal bed, and anastomosed to vaginal introitus. Primary donor-site closure was accomplished in all patients with conspicuous scars. All flaps survived and the authors reported a normal appearance of external genitalia with sufficient neovaginal depth and width. During the short follow-up (6-14 mo), two patients reported satisfactory sexual intercourse.     

A medially based abdominal transposition flap for large soft tissue defects of the anterior chest wall

. Large defects of the anterior chest wall need not necessarily be covered with a muscle flap if the ribs are intact. A medially based transposition flap from the abdomen with borders at the posterior axillary line, the superior iliac spine, the inguinal ligament, and the umbilicus is described. This flap receives its blood supply through the periumbilical subcutaneous plexus and perforators of the epigastric vessels which cross the midline. The donor-site can be closed primarily in a V-to-Y fashion and the flap can cover defects of the anterior and anterolateral chest wall up to the clavicle. In 17 cases this flap proved to be highly reliable, it is easy to perform and it has an extremely low donor-site morbidity with a good aesthetic result when compared to muscle flaps.     

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation.MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline.ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively.ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.     

DIEAP flap selection for unilateral breast reconstruction: a comparison of flap side harvest

Background

For breast reconstruction, the deep inferior epigastric artery perforator (DIEAP) flap can be harvested at the same side as that in mastectomy (ipsilateral) or from the contralateral hemi-abdomen. This paper seeks to establish the benefits of either side of DIEAP flap harvest, on the basis of our experience and a literature review.

Methods

We analysed our experience with the DIEAP flap and compared the two different technical approaches to flap harvesting. Using the internal mammary vessels as the standard recipient, with comparable vessels on either side, we compared the differences between harvesting on the contralateral and ipsilateral hemi-abdomen and analysed any references to it in the literature.

Results

Seventy-three DIEAP flaps were harvested for breast reconstruction, over a 2-year period, by the two senior authors. Of the 44 cases where the ipsilateral hemi-abdomen was used, this was the routine primary choice of the operating surgeon in 42 cases. The contralateral hemi-abdomen was the preferred choice in 29 cases. We accessed 302 papers related to the topic of breast reconstruction using a DIEAP flap, of which 63 papers were reviewed, based on the abstracts. Only six of these papers mentioned their routine or preferred choice of the hemi-abdomen.

Conclusions

There appears to be no consensus in the literature as to the preferred side of DIEAP flap harvest, if the perforators are of similar calibre and ease of dissection. Modern DIEAP flap harvest is based on the preoperative selection of the most reliable perforator. In relation to mastectomy defect, this may be on the ipsilateral or contralateral. Level of Evidence: Level IV, prognostic/risk study     

Potentiation of transforming growth factor (TGF-β1) by natural coral and fibrin in a rabbit cranioplasty model

The association of a biodegradable material and a growth factor could be of clinical value for treating bone defects. We therefore tested the association of transforming growth factor (TGF-1) in fibrin glue and coral granules to heal skull defects in rabbits. Adult rabbits underwent a double trepanation symmetrically in both parietal bones. Using histomorphometry, we compared bone repair after 1 month in control animals (n=5) and in animals treated with either TGF-1 as a single injection of 1 g in methylcellulose (n=5) or in fibrin glue (n=5), or with coral granules in fibrin glue (n=4) or with coral granules and TGF-1 1 g in fibrin glue (n=5). We measured the diameter of the remaining defect and the surface of the bone growth. TGF-1 without coral in either methyl cellulose or fibrin induced a partial closure of the defect as assessed by a significant decrease in the defect diameter, compared with the control group. However, the association of TGF-1 in fibrin and coral induced an area of the bone growth higher than in any other groups (P<0.05). Two months after surgery, this triple association induced a better healing of the defect than coral alone or control group. In each group treated with TGF-1, the mineralization rate was increased not only at the treated side but also in the contralateral defect which was untreated, suggesting a diffusion of the growth factor. Indeed, when pooled together, the diameter of the defect at the contralateral side of 14 animals that had received TGF-1 was reduced compared with the control group. Significant coral granules resorption occurred between month 1 and 2 and was unchanged by the addition of TGF-1. In conclusion, the triple association of coral granules and TGF-1 in fibrin could be of interest for treating bone defects.     

Repair of hand scars by a dilated deep inferior epigastric artery perforator flap

We have investigated the mapping of several deep inferior epigastric artery perforator (DIEAP) vessels in each patient, the effect of tissue expansion on the variation in the diameter of the DIEAP vessel, and the clinical effect of repair of hand scars by applying a dilated DIEAP flap. From 2000 to 2009, we did some research on this flap using a Doppler probe and computed tomographic (CT) angiography, and found that the inferior epigastric arteries are distributed between 4 cm above the umbilicus and 8 cm below the umbilicus. Most of the vessels are distributed in zones I, II, and III according to the Rand zonal approach. The arteries were rarely found in zone IV, and there was a relatively dense distribution of perforators in the nearby umbilical plane. Most of the biggest perforators were located in the peripheral umbilicus, and the mean (SD) diameter of perforator vessels was increased by 33% (8)% after expansion. The dilated DIEAP flap was used to treat 18 cases of hand scars. After the operation, 16 flaps survived; the two that did not, had slight blood flow defects in the distal portion of the flap, and the overall effects of the treatment were good. After the DIEAP flaps had been expanded for a long time, blood supply and the area of the flap are increased. The flap generated by this method is thin, has good resistance, and a nice appearance, and is therefor a better method for treating wounds of the hand and arm, and claw hand.     

The utility of multidetector-row computed tomography angiography for evaluating perforators of fibular osteocutaneous flaps

Multidetector-row computed tomography angiography (MDCTA) can be used to visualize small vessels and has been used to search for perforators in deep inferior epigastric artery perforator flaps and anterolateral thigh flaps. Fibula osteocutaneous flaps are often used for mandibular reconstruction, but questions remain about the reliability of these flaps and the variety of their perforators. Eight patients who were candidates for mandibular or pedal reconstruction with a fibula osteocutaneous flap were prospectively evaluated with MDCTA and Doppler sonography. We evaluated the number, position, and course of perforators with MDCTA. The perforators were classified, and intraoperative findings were compared with those of Doppler sonography and MDCTA. MDCTA accurately identified the perforators and showed a satisfactory concordance with intraoperative findings. The high spatial resolution of MDCTA allows the perforators' origin, course, and type to be precisely described. Eighteen vessels were identified with MDCTA, and on average, 2.3 vessels were identified in the leg of each patient. The rate of concordance with operative findings was 87.5% for MDCTA. With MDCTA, flap perforators can be accurately evaluated before surgery in a manner not possible with traditional angiography or Doppler sonography. Reliable perforators can be chosen, and detailed operative plans can be made.     

An assessment of the anatomical basis of the thoracoacromial artery perforator flap

BACKGROUND:

Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap.

METHODS:

A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels.

RESULTS:

The perforators through the PM muscle to the overlying skin included three regional groups: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery.

DISCUSSION:

The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.     

Reconstruction of large soft tissue defects of the lower torso with rectus abdominis musculocutaneous flaps

Summary Seven large defects of the lower torso were closed with rectus abdominis musculocutaneous flaps: two large roin defects, three abdominal wall defects, and two open lateral pelvic wounds. Five of the flaps were inferiorly based and two superiorly based. The donor site was closed primarily unless a large skin paddle was taken, in which case the donor site was skin grafted. The central location, excellent blood supply (superior and inferior epigastric arteries plus abundant cutaneous perforators), and length and thickness of the rectus abdominis muscle make it a versatile flap for abdominal wall and lower torso defects.